Health Assessment Chapter 16 Practice Questions
Which vision acuity reading indicates blindness?
20/200
Which of the following assessment findings suggests a problem with the client's cranial nerves?
A client's extraocular movements are asymmetrical and she complains of diplopia.
A nurse assesses a client's pupils for the reaction to light and observes that the pupils are of unequal size. What should the nurse do next in relation to this finding?
Ask the client about previous trauma to the eyes
Which technique by the nurse demonstrates proper use of the ophthalmoscope?
Asks the client to fix the gaze upon an object and look straight ahead
A light is pointed at a client's pupil, which then contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon?
Consensual reaction
A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity?
Have the client hold the Jaeger card 14 inches from the face & read with one eye at a time
A client is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left noted in the client's medical record supports this diagnosis?
Increased intraocular pressure
When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc?
Medially toward the nose
The nurse observes a young client holding a newspaper up close to read. Which condition does the nurse suspect this client suffers from?
Myopia
You note anterior bulging of the physiologic cup when performing a funduscopic examination of your client's eyes. What would you document?
Papilledema
The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed?
Presbyopia
When testing the near reaction, an expected finding includes which of the following?
Pupillary constriction on near gaze; dilation on distant gaze
Which of the following is a symptom of the eye?
Scotomas Explanation: Scotomas are specks in the vision or areas where the client cannot see; therefore, this is a common and concerning symptom of the eye. Tinnitus is a ringing in the ears, dysphagia is difficulty swallowing, and rhinorrhea is a "runny nose."
The nurse is caring for a 63-year-old client who can neither read nor speak English. What would be the appropriate chart to use to assess this client's vision?
Snellen E
A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client?
Use of safety equipment
A client tells the nurse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with
Vitamin A deficiency
The nurse should make it a priority to assess which client for papilledema?
a 45-year-old suspected of experiencing a subarachnoid hemorrhage
The nurse notes that the pupil of a client's left eye constricts when a light is shined into the right eye. How should the nurse document this finding?
consensual light response present in left eye
An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to
corneal damage
When assessing the fundus of the eye, the nurse recognizes which normal characteristic represented in dark-skinned individuals?
fundus is grayish brown with a purplish cast
The nurse is using the ophthalmoscope to examine the client's eyes. The nurse holds the scope
in the right hand for the right eye and in the left hand for the left eye
The optic nerves from each eyeball cross at the
optic chiasma
What part of the eye receives and transmits visual stimuli to the brain for processing?
retina
On visual confrontation testing, a client with a recent stroke cannot see the examiner's fingers on the entire right side with either eye covered. Which of the terms would describe this finding?
right homonymous hemianopsia
Which of the following is a symptom of the eye?
scotomas
When visual acuity is tested using the Snellen eye chart, which result suggests better distance vision?
30, 20
Which of the following statements most accurately describes the maintenance of normal intraocular pressure?
Aqueous humour is continuously circulating through the eye with production equalling drainage.
The middle layer of the eye is known as the
choroid layer
An adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible
increased intracranial pressure
A nurse is inspecting a client's eyes to assess for the possibility of detached retinas. The nurse is aware that which of the following is the function of the retina?
Transforms light rays into nerve impulses that are conducted to the brain
A client presents to the clinic reporting sudden visual loss in the left eye. What is the nurse's priority action?
Notify the healthcare provider immediately.
The nurse observes an inward turning of the lower lid in a 77-year-old client. The nurse documents
entropion
The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should
position the client 609.6 cm (20 ft) away from the chart.
A client is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?
She can see at 20 feet what a normal person could see at 100 feet.
As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?
The client and the examiner see the examiner's finger at the same time
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?
lacrimal apparatus
What is the primary purpose of the health history in relation to the eyes?
to identify changes
A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent
macular degeneration
When assessing the eye, the nurse recognizes that which physical structures of the face limit the normal visual field that a client can experience? Select all that apply.
the brow the medial aspect of the nose the cheek
When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record?
Exotropia Correct Explanation: With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes. Presbyopia is impaired near vision.
A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result?
Focused on the bridge of the nose
A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results?
The larger the bottom number, the worse the visual acuity
The nurse has tested the near visual acuity of a 45-year-old client. The nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. The nurse determines that the client has understood the instructions when the client says that presbyopia is usually due to
decreased accommodation.
A nurse notices a middle-aged client in the waiting room pick up a magazine to read while she waits to be seen. She opens the magazine and then extends her arms to move it further from her eyes. Which condition does the nurse most suspect in this client?
presbyopia
